Download Percutaneous Transluminal Coronary Angioplasty in a Patient with

Case Report / Olgu Sunumu
DOI: 10.4274/haseki.2023
Percutaneous Transluminal Coronary Angioplasty in a
Patient with Congenital Diaphragmatic Bochdalek Hernia
Konjenital Diyafragmatik Bodalek Hernili Hastada Perkütan Koroner
Anjiyolplasti
Mehmet Mustafa Can
Haseki Education and Research Hospital, Clinic of Cardiology, İstanbul, Turkey
Abs­tract
Özet
Herniations through the foramen of Bochdalek are very rare
diaphragmatic hernias in adults. Even in infants, respiratory
distress syndrome manifests as a complication of a disease, it
may be asymptomatic until late in life. Although the presenceof
atherosclerotic process do not differ from normal, angiographic
characteristics of these vessels, such as the orifice configuration,
exit angulation, the route of the artery and the location of the
stenotic lesions are much more different. We report an extremely
rare case of percutaneous treatment of a coronary stenosis in a
patient whose heart was displaced to the right side of the chest
due to congenital diaphragmatic Bochdalek hernia. (The Me­di­cal
Bul­le­tin of Ha­se­ki 2015; 53: 107-9)
Bodalek açıklığından çıkan difagragmatik hernilerin erişkinlerde
sıklığı azdır. Çocuklarda respiratuvar stres sendromu olarak
komplike olabilse de yaşamın son dönemlerine kadar
asemptomatik seyredebilir. Atresklerotik süreç normal
popülasyondan farklı seyretmese de damarların giriş şekli, ters
açılanması, arterin izleyiş yönü ve darlık lezyonları gibi anjiyografik
karakteristikleri biraz daha farklıdır. Biz bu olguda konjenital
difagragmatik herni yüzünden kalbi göğsün sağ tarafına doğru
yer değiştiren hastada yapılan perkütan koroner işlemini anlattık.
(Ha­se­ki T›p Bül­te­ni 2015; 53: 107-9)
Anahtar Sözcükler: Bodalek herni, anjiyoplasti
Key Words: Bochdalek hernia, angioplasty
Case Report
the patient, coronary angiogram was performed. The
transfemoral approach was used but the left coronary
arteries could not be cannulated with a standard left
Judkins 6 F catheter. The positions of the aorta and coronary
ostium were changed due to the displacement of the heart
as a consequence of the hernia. Coronary ostiums were
more vertical and the distance and the angle between
the contralateral part of the aorta and coronary ostium
were different from the normal coronary anatomical
positions. We could not cannulate the coronary arteries
in spite of repeated attempts using different maneuvers
with the Judkins catheter which had a short and bent tip.
For easy back-up and good engagement to the coronary
artery ostium, extra back up (EBU) diagnostic catheter
was chosen. Severe lesions were seen in the proximal and
mid segments of the left anterior descending artery (LAD)
(Figure 2). The right and circumflex arteries were normal.
A seventy-year-old male with a history of uncontrolled
hypertension and dyslipidemia was admitted to our
hospital with typical anginal pain at rest. At the time
of admission, his blood pressure and pulse rate were
150/90 mmHg and 88 beats per minute, respectively.
Physical examination showed a diminished breath sounds
at auscultation. The electrocardiogram on admission
revealed reduction in R wave voltage across the chest
leads. Telecardiography showed sliding of the heart to
the right side of the thorax and presence of bowels on
the left side of the thorax (Figure 1). Initial diagnosis
was acute coronary syndrome and laboratory evaluation
showed normal cardiac enzymes and high troponin
levels. Gastroenterology consultation was assessed and
congenital diaphragmatic hernia was diagnosed after
evaluation. Due to unstable cardiovascular condition of
Ad­dress for Cor­res­pon­den­ce/Ya­z›fl­ma Ad­re­si: Mehmet Mustafa Can
Haseki Education and Research Hospital, Clinic of Cardiology, İstanbul, Turkey
Phone: +90 212 459 40 41 E-mail: [email protected]
Received/Gelifl Tarihi: 01 August 2014 Ac­cep­ted/Ka­bul Ta­ri­hi: 09 September 2014
107
Haseki T›p Bülteni,
Galenos Yay›nevi taraf›ndan bas›lm›flt›r.
The Medical Bulletin of Haseki Training and Research Hospital,
published by Galenos Publishing.
Mehmet Mustafa Can, Angioplasty Bochdalek Hernia
Figure 1. Displacement of the heart to the right side of thorax and
presence of bowel images on the left side of the thorax
Figure 3. Left coronary angiogram in left anterior oblique position
after stenting proximal and mid left anterior descending
Discussion
Figure 2. Extra back-up catheter comes inro contact with a line
on the aortic wall and is supported by the contralateral part of the
left coronary artery ostium and severe lesions in proximal and mid
segments of left anterior descending coronary artery in left anterior
oblique cranial view. And presence of bowel imges on the lateral
part of the angiographic view
Subsequently, after changing the diagnostic catheter with
guiding EBU catheter, percutaneous transluminal coronary
angioplasty for the stenosis in the LAD was performed.
The lesions were directly stented with 3.0x25 mm and
3.0x18 mm bare metal stents, respectively (Figure 3).
Following the procedure, the patient was discharged on
day three with conventional double-antiplatelet treatment
(aspirin and clopidogrel). At one year, the patient was still
asymptomatic and in good clinical condition.
108
The goal of coronary angiography is to define the
coronary anatomy and the degree of luminal obstruction
of the coronary arteries. It is most commonly used
to determine the presence and extent of obstructive
coronary artery disease and to assess the feasibility
and appropriateness of various forms of therapy,
such as revascularization by percutaneous or surgical
interventions. It can be considered as a feasible and safe
procedure in routine daily practice. Despite improvements
in coronary stent designs, difficulties in delivery may still
be encountered in certain rare circumstances which affect
the heart and/or coronary artery anatomical positions
such as dextrocardia, hernia and coronary anomalies (1).
Since there are no standardized guidelines to select a
catheter for these abnormalities, the choice of diagnostic
and interventional guide catheters that provide adequate
access to the coronary arteries and support for stent
deployment is much more complex than routine invasive
procedures in such abnormalities. The anatomy of this
anomaly and the operator’s preferences are key factors for
performing angiography successfully (2-5). The operators
are occasionally faced with multiple technical challenges
that require frequent catheter changes to find the best
fitting catheter. For the safety and effectiveness of the
procedure, and to prevent the prolonging of time, an
optimal guide must be chosen to provide a stable platform
for the operator to advance devices to the coronary
artery through the lesion. In daily practice, the most
commonly used guides are Judkins, Amplatz and EBU
Mehmet Mustafa Can, Angioplasty Bochdalek Hernia
References
guides. Each guide has different properties for different
anatomical variations. Due to vertical configuration of the
coronary orifice in our case, Judkins catheter was not the
appropriate choice for the procedure. For this reason EBU
guiding catheter was chosen. It has a longer secondary
curve that is designed to rest on the opposite aortic
wall for strong and stable platform. Although Bochdalek
hernia is not the main subject of this case, the abnormal
anatomic variation, angulation and the course of coronary
arteries in these patients make invasive procedures more
complex for the operator. To prevent wasting time in trying
different guiding catheters and techniques, the operator
must select proper equipment, and special consideration
should be given during invasive procedures.
1. Mullins ME, Stein J, Saini SS, Mueller PR. Prevalance of
incidental Bochdalek’s hernia in a large adult population. Am
J Roentgenol 2001;177:363-6.
2. Topaz O, DiSciascio G, Goudreau E, Cowley MJ, Nath A,
Kohli RS, Vetrovec GW. Coronary angioplasty of anomalous
coronary arteries: notes on technical aspects Cathet
Cardiovasc Diagn 1990;21:106-11.
3. Oral D, Dağalp Z, Pamir G, Alpman A, Omürlü K, Erol C,et al.
Percutaneous transluminal coronary angioplasty of anomalous
coronary arteries:case reports. Angiology 1996;47:77-82.
4. Udaya Prashant P. Successful angioplasty of anomalous
coronary arteries with total occlusions. J Invasive Cardiol
2012;24:228-32.
5. Pellizzón OA, Scaglione L, Chiesa AE, Gonzalez MD.
Spontaneous termination of ventricular fibrillation in a
patient with congenital coronary anomaly. Congenit Heart
Dis 2012;7:109-12.
109